“| was told that (quote): "Courtney was on a quantity of different medication for her…”

The coroner’s concerns

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— | was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is “Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SCH il an they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." | was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. | believe such a problem could put other children’s lives at risk in similar circumstances.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0224

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0